Gross Incompetence Cited in Rikers Island Death

A New York State watchdog agency overseeing jails and prisons has found that gross incompetence by medical personnel and correction officers at Rikers Island led to the death of a mentally ill inmate who was found naked and covered in feces after being locked in a cell for six days.

In a report, the agency, the New York State Commission of Correction, called for the Justice Department to investigate possible civil rights violations, saying the details of the inmate’s death “shock the conscience.” It is not clear, though, whether anyone received significant punishment.

The inmate, Bradley Ballard, died on Sept. 11, 2013, after he was deprived of insulin for diabetes and locked in his cell without food or running water for nearly a week. Though correction officers, doctors and inmates were visibly repulsed by the stench coming from his cell, none of them entered or sought help.

The commission’s report, which is dated Dec. 16, and was obtained by The New York Times, though not released publicly, describes how a warden, an assistant deputy warden, guards, doctors, mental health clinicians, nurses and others made at least 57 visits to Mr. Ballard’s cell as he slowly deteriorated over a six-day period but did nothing to assist him.

The commission’s report makes clear that blame for the death lies squarely with the city’s correction and health agencies, as well as the private jail health contractor, Corizon Inc.

Mr. Ballard was locked “in his cell for six days prior to his death,” the report said, “and was denied access to his life supporting prescribed medications, denied access to medical and psychiatric care, denied access to essential mandated services such as showers and exercise periods and denied running water for his cell.”

Joseph Ponte, the correction commissioner, would not say whether any officers were fired or disciplined. “We continue to investigate and have adjusted our practices to ensure that a similar tragedy does not happen again,” he said in a statement.

Dr. Sonia Angell, a deputy commissioner for the New York City Department of Health and Mental Hygiene, said the Corizon mental health unit chief was transferred to a smaller jail with fewer responsibilities.

Susan Morgenstern, a Corizon Health spokeswoman, said the contractor conducted an investigation, but could not “comment further because of legal reasons.”

The Justice Department plans to review the report, a representative said.

From the time Mr. Ballard entered Rikers for a parole violation in June 2013 until his death, medical staff failed to adequately care for his diabetes, the report said. At one point he went 11 days without insulin, it stated.

This failure resulted in increasingly erratic behavior, the report said. After making a lewd gesture at a female guard, he was locked in his cell and never emerged again.

Mr. Ballard was observed on surveillance video banging on his cell door. At one point he wrapped what the report described as a ligature around his testicles five times, cutting off circulation. The smell became so bad that an officer sprayed a deodorizer outside, but never went in.

At 9:30 p.m. on Sept. 10, an officer wrote in a logbook that Mr. Ballard was lying in his cell naked and having difficulty breathing. The officer told another guard to notify the clinic.

A doctor and a nurse did not arrive on the scene until 10:56 p.m. Neither they nor correction officers entered his cell and instead at 11:01 p.m. directed two inmates to carry him out and put him on a gurney.

At 11:29 p.m., Mr. Ballard went into cardiac arrest at a jail clinic. He was transferred to Elmhurst Medical Center where he was pronounced dead at 1:31 a.m.

A version of this article appears in print on , on Page A20 of the New York edition with the headline: Gross Incompetence Cited in Rikers Death. Order Reprints | Today’s Paper | Subscribe